Currently, DHFS may obtain from insurers information DHFS needs to identify
an MA recipient who is eligible for benefits under a disability insurance policy or, if
enrolled as the dependent of a beneficiary, would be eligible for benefits; claims
submittal information; and types of benefits provided under the policy. DHFS must
enter into an agreement with the insurer that identifies the information to be
disclosed, safeguards confidentiality, and specifies how the insurer's reasonable
costs for this work will be determined and paid by the state. Insurers must provide
the information within specified deadlines, and the commissioner of insurance may
initiate enforcement proceedings for noncompliance.
Under this bill, DHFS may receive health care services coverage information
from, in addition to insurers, self-insured plans, service benefits plans, and
pharmacy benefits managers (third parties). DHFS may also gather information
about BadgerCare recipients who are eligible or who would be eligible as dependents
for health care coverage from a third party. DHFS must pay compensation for
providing the information. DHFS may notify the attorney general of third parties,
other than insurers, that fail to provide information requested.
Under the bill, third parties must accept assignment to DHFS of an individual's
right to receive payment from the third party for a health care item or service paid
for under MA, BadgerCare, or a program administered under MA under a federal
waiver. Third parties must also accept DHFS's right to recover third-party
payments for which assignment had not been accepted. A third party must respond
to an inquiry by DHFS concerning a claim for payment of a health care item or service
if the inquiry is made within 36 months after the item or service is provided. Further,
third parties must agree not to deny a DHFS claim on the basis of certain
circumstances, if submitted less than 36 months after the health care item or service
is provided and if action by DHFS to enforce its rights is commenced less than 72
months after DHFS submits the claim.
Under current law, nursing home reimbursements for care provided to MA
recipients are determined under a system that considers, among other things, direct
care costs, as adjusted by DHFS for regional labor cost variations. For this purpose,
DHFS treats the counties of Dane, Iowa, Columbia, and Sauk as a single labor region.
This bill adds Rock County to this labor region.
Currently, under the MA waiver community integration program for persons
relocated from, or meeting requirements of, MA reimbursements to nursing homes
(commonly known as CIP II), DHFS provides enhanced MA reimbursement for up
to 150 persons who are diverted from imminent entry into nursing homes. Enhanced
reimbursement for more than 150 persons must be approved by JCF. This bill
requires the approval from the secretary of administration instead of from JCF.
Under current law, some individuals who are eligible for MA are also eligible
for Medicare Part D, which is the portion of the federal health insurance program
that provides prescription drug coverage for individuals who are, generally, 65 years
of age or older or disabled. Enrollment in Medicare Part D is voluntary. Not all Part
D plans in which individuals may enroll cover all of the prescription drugs that may
be covered under Medicare Part D.
Under this bill, if an individual is eligible for both MA and Medicare Part D, MA
will not pay for any prescription drug for which there may be coverage under
Medicare Part D, whether or not the individual is enrolled in Medicare Part D and,
if he or she is enrolled, whether or not the individual's Part D plan covers the drug.
Currently, some individuals who are eligible for MA are also eligible for
Medicare, a federal health insurance program for individuals who are, generally, 65
years of age or older or disabled. Medicare Part A covers hospital and related
services, and coverage is automatic. Medicare Part B covers outpatient, nursing, and
physician services and various other health care services, such as diagnostic tests.
Enrollment in Medicare Part B is voluntary, and an enrollee must pay a premium.
Current law does not require an individual who is eligible for both MA and Medicare
to enroll in Medicare Part B, and DHFS reimburses providers under MA for services
that would be covered under Medicare Part B if the individual were enrolled in
Medicare Part B.
This bill provides that DHFS may require an individual who is eligible for
Medicare and for MA services under a number of eligibility categories to enroll in
Medicare Part B as a condition of receiving those MA services. If DHFS requires an
individual to enroll in Medicare Part B, DHFS must pay the monthly premiums for
the coverage. Because MA does not pay for benefits to which an individual is entitled
under another benefit program, MA would no longer pay for any benefits that are
covered under Medicare Part B after the individual enrolls in Medicare Part B.
Currently, one category of MA recipients is termed "categorically needy"; these
persons have incomes and resources at the eligible levels and can be determined to
be retroactively eligible for MA for a certain period of months. Another category of
recipients is termed "medically needy"; these persons have resources at eligible
levels and incur medical expenses that, if paid, bring their incomes to eligible levels.
Currently, if an MA applicant is found to be retroactively eligible as a "categorically
needy" recipient and a provider has billed the recipient directly for services provided
during the retroactive period, the provider, upon notice that the applicant is
retroactively eligible, must submit claims for MA payment to DHFS. When paid by
DHFS, the provider must reimburse the MA recipient for payment the recipient or
another person made to the provider for services provided to the recipient during the
retroactively eligible period. Regardless of the amount the provider has charged the
MA recipient, the provider may not be required to reimburse the recipient more than
the amount that the provider is paid for the services by MA.
This bill eliminates the prohibition on requiring a health care provider to
reimburse for services paid for by a "categorically needy" MA recipient in an amount
that is greater than the provider is paid for the services under the MA program.
Instead, the bill requires that the health care provider reimburse the MA recipient
or another person in the amount that the recipient or other person has paid the
provider for the recipient's care and extends this repayment requirement to
"medically needy" MA recipients.
Currently, in addition to providing family planning as a benefit to MA
recipients, DHFS administers, under a waiver of federal Medicaid laws, a
demonstration project to provide family planning services to women between the
ages of 15 and 44 with family incomes of not more than 185 percent of the federal
poverty level.
This bill requires DHFS to request an amended federal waiver for the
demonstration project to provide family planning under MA to men between the ages
of 15 and 44 and to increase the financial eligibility limitation under the
demonstration project to 200 percent of the federal poverty level.
Children
Under current law, DHFS provides or oversees county provision of, various
services to children and families. These services include services for children in need
of protection or services and their families; adoption services; licensing of child
welfare agencies, foster homes, group homes, day care centers, and shelter care
facilities; investigating cases of suspected child abuse or neglect; providing a state
supplemental food program for women, infants, and children; and distributing
funding for children's community programs, child abuse and neglect prevention
programs, food distribution programs, domestic abuse services, tribal adolescent
services, community action programs to assist poor persons, and a brighter futures
initiative to prevent delinquent behavior, alcohol and other drug abuse, child abuse
and neglect, and nonmarital pregnancy.
This bill creates the Department of Children and Families (DCF), effective July
1, 2008, and transfers from DHFS to DCF the duty to provide or oversee the provision
of these services. The bill also renames DHFS the Department of Health Services.
Under current law, DWD administers the Wisconsin Works (W-2) program,
which provides work experience and benefits for low-income custodial parents, job
search assistance, and child care subsidies. DWD also administers the program for
establishing and enforcing child and spousal support and establishing paternity and
medical support liability. This bill transfers from DWD to DCF the responsibility for
administering these programs.
Under current law, DHFS administers the Child Abuse and Neglect Prevention
Program, under which DHFS awards grants to counties and Indian tribes that offer
voluntary home visitation services to first-time parents who are eligible for MA.
Current law requires DHFS to determine the amount of a grant awarded to a county
or an Indian tribe in excess of the statutory minimum grant amount of $10,000 based
on the number of births that are funded by MA in that county or the reservation of
that Indian tribe in proportion to the number of those births in all of the counties and
the reservations of all of the Indian tribes to which grants are awarded. Currently,
no more than six rural counties, three urban counties, and two Indian tribes may be
selected to participate in the program.
This bill requires DCF, beginning January 1, 2009, to determine the amount of
a grant in excess of the statutory minimum based on the number of births that are
funded by MA in a county or a reservation of an Indian tribe without regard to the
number of those births in other counties and reservations. The bill also eliminates
the caps on the number of counties and Indian tribes that may be selected to
participate in the program.
The bill directs DCF to award grants to applying counties, local health
departments, Indian tribes, private nonprofit agencies, and local partnerships
(organizations) to provide voluntary one-time home visits to all first-time parents
in the community served by the organization. The purposes of the home visits are
to provide those parents with basic information regarding infant health and
nutrition, the care, safety, and development of infants, emergency services for
infants, and shaken baby syndrome and impacted babies; to identify the needs of the
parents; and to provide the parents with referrals to programs, services, and other
resources that may meet those needs.
Recently, the U.S. Congress enacted the Adam Walsh Child Protection and
Safety Act of 2006, which requires the states to conduct criminal records checks,
including fingerprint-based checks of national crime information databases, of
prospective foster or adoptive parents and to check any child abuse or neglect
registry maintained by any other state in which a prospective foster or adoptive
parent or any other adult living in the home of that prospective parent (adult
resident) has resided in the preceding five years before the prospective foster or
adoptive parent may be finally approved for placement of a child, regardless of
whether foster care maintenance or adoption assistance payments will be provided
on behalf of the child.
This bill conforms state law relating to background checks of prospective foster
parents, adoptive parents, and adult residents to federal law, as affected by the Adam
Walsh Act.
Under current law, if a court assigned to exercise jurisdiction under the
Children's Code (juvenile court) issues an order placing, or maintaining the
placement of, a child outside the home, the order must include findings that
continued placement of the child in the home would be contrary to the welfare of the
child, that reasonable efforts have been made to prevent the removal of the child from
the home, and that reasonable efforts have been made to achieve the goal of the
child's permanency plan, which is a plan designed to ensure that the child is
reunified with his or her family whenever appropriate or that the child quickly
attains a placement providing long-term stability. This bill requires the juvenile
court to make the finding that reasonable efforts have been made to achieve the goal
of the child's permanency plan in a termination of parental rights order.
Under current law, in an action affecting the family (for example, a divorce
proceeding), if the circuit court finds that neither parent is able to care for the child
adequately or is fit and proper to have care and custody of the child, the circuit court
may declare the child to be in need of protection or services and transfer legal custody
of the child to the county or to a licensed child welfare agency. This bill requires a
circuit court that so transfers legal custody of a child to refer the matter to the
juvenile court intake worker, who must conduct an intake inquiry to determine
whether a petition alleging the child to be in need of protection or services should be
filed with the juvenile court, and to include in the order transferring legal custody
of the child a finding that placement of the child in his or her home would be contrary
to the welfare of the child and, subject to certain exceptions, a finding that reasonable
efforts have been made to prevent the removal of the child from the home.
The bill also requires a juvenile court, when ordering a child to be placed outside
the home under the supervision of a county or, in Milwaukee County, DHFS, to order
the child into the placement and care responsibility of the county or DHFS and to
assign the county or DHFS primary responsibility for providing services to the child.
In addition, the bill requires a county, DHFS, or DOC, when placing a child outside
the home under a voluntary agreement, to explicitly state in the voluntary
agreement that the county, DHFS, or DOC has placement and care responsibility for
the child and has primary responsibility for providing services to the child.
This bill requires DWD to provide a child care quality rating system for child
care providers licensed by DHFS that receive reimbursement under the W-2
program or that volunteer for rating under the system. The rating information must
be made available, including on DWD's Internet site, to parents, guardians, and legal
custodians of children who are recipients, or prospective recipients, of care and
supervision from a child care provider.
This bill increases the age-related basic maintenance rates that are paid by the
state or a county to a foster parent for the care and maintenance of a child.
This bill permits DHFS in fiscal year 2007-08 and DCF in fiscal year 2008-09
to expend not more than a total of $500,000 in certain federal revenues received in
fiscal year 2006-07 or 2007-08 for unexpected or unusually high-cost out-of-home
care placements of Indian children ordered by tribal courts.
Public assistance
Currently, under Senior Care, DHFS reimburses pharmacists and pharmacies
for providing prescription drugs to elderly persons at reduced rates. DHFS provides
payments from general purpose revenues, rebate payments made by prescription
drug manufacturers, and federal funds.
This bill establishes the health care quality fund, consisting of moneys obtained
from an increase in cigarette and other tobacco products taxes and certain other
moneys and used as another source of Senior Care funding.
Under current law, a person who applies for benefits under Wisconsin Works,
MA, or the food stamp program must provide, as a condition of eligibility, a
declaration of citizenship or satisfactory immigration status. Federal law provides
that no federal moneys will be provided to a state for MA expenditures made on
behalf of a person who declares that he or she is a citizen or national of the United
States unless the person presents satisfactory documentary evidence of citizenship
or nationality. Federal law specifies the documentary evidence that is satisfactory
and certain exemptions to the requirement. This bill conforms state law to federal
law.
Under the Chronic Disease Program, DHFS currently provides financial
assistance for the cost of medical care to persons with chronic kidney disease, cystic
fibrosis, and hemophilia.
This bill requires health insurers, self-insured plans, service benefits plans,
and pharmacy benefits managers (third parties) to provide to DHFS information
from their records to identify persons receiving benefits under the Chronic Disease
Program and under Senior Care who are eligible, or would be eligible as dependents,
for third-party health care coverage and imposes other requirements on third
parties that are similar to those by which third-party liability is determined and
enforced under MA.
Under current law, DHFS provides benefits under the federal Food Stamp
Program and contracts with DWD for administration of an employment and training
program for Food Stamp Program recipients. This bill transfers, administration of
the employment and training program for food stamp recipients to DHFS, which may
contract with county departments of social services and human services and with
tribal governing bodies to administer the program.
Under current law, an individual is ineligible for food stamps in any month in
which the individual is not in compliance with various child support enforcement
requirements, such as refusing to cooperate with efforts to establish paternity with
respect to a child or being delinquent in the payment of child support. This bill
removes noncompliance with the child support enforcement requirements as a basis
for ineligibility for food stamps.
Wisconsin Works
Currently the Wisconsin Works (W-2) program provides work experience and
benefits for low-income custodial parents who are at least 18 years old; job search
assistance to noncustodial parents who are required to pay child support, to minor
custodial parents, and to pregnant women who are not custodial parents; and child
care subsidies for certain parents who need child care services to participate in
various educational or work activities. W-2 is administered by DWD, which
contracts with W-2 agencies to administer W-2 on the local level.
The work components under W-2, called employment positions, consist of three
categories: trial jobs, community service jobs, and transitional placements. A
participant in an employment position must search for unsubsidized employment
the entire time that he or she is participating in the W-2 employment position.
Under current law, DWD is directed to continue the creation and implementation of
a subsidized work program.
This bill eliminates the latter directive and requires DWD to conduct and
evaluate, from January 1, 2008, to December 31, 2009, a real work, real pay pilot
project, limited to 500 participants and conducted in at least one of the areas of the
state established for administering the W-2 program that is located in Milwaukee
County and in at least two areas that are not in Milwaukee County. Under the
project, a W-2 agency pays a wage subsidy, which may not exceed the federal
minimum wage for no more than 30 hours of work per week, to an employer that
employs a project participant. The employer is also reimbursed for up to 100 percent
of federal social security taxes, state and federal unemployment contributions, and
worker's compensation insurance premiums paid on behalf of a participant. An
employer that employs a participant and receives a wage subsidy must agree to make
a good faith effort to retain the participant as an unsubsidized employee after the
wage subsidy ends if the participant successfully completes participation in the pilot
project.
Under current law, a person who is eligible for W-2 and who is the custodial
parent of a child who is 12 weeks old or less may receive a monthly grant of $673 and
may not be required to work in a W-2 employment position. This bill provides that
the custodial parent of a child who is 26 weeks old or less may receive the monthly
grant and may not be required to work in a W-2 employment position. In addition,
the bill provides that an unmarried woman who would be eligible for W-2 except that
she is not a custodial parent may also receive a monthly grant of $673 and may not
be required to work in a W-2 employment position if she is in the third trimester of
a medically verified pregnancy that is at risk and that renders the woman unable to
participate in the workforce.
Under W-2, an individual who is the parent of a child under the age of 13 or,
if the child is disabled, under the age of 19, is eligible for a child care subsidy if the
individual needs child care services to participate in various educational or work
activities and satisfies other eligibility criteria, one of which is that the individual's
family income may not exceed 185 percent of the poverty line. If an individual is
already receiving a child care subsidy, however, family income may be as high as 200
percent of the poverty line. This bill changes these maximum family income levels
to 175 percent of the poverty line for an individual who is first applying for a child
care subsidy and to 190 percent of the poverty line for an individual who is already
receiving a subsidy.
Health
Under current law, DHFS administers a program under which individuals with
a human immunodeficiency virus (HIV) infection may be reimbursed for the cost of
the drug azidothymidine (AZT) or other cost-effective alternatives. DHFS also
administers a program under which individuals with an HIV infection may have
their health insurance premiums subsidized if they are on unpaid medical leave, or
have had to discontinue their employment or reduce their hours, because of a medical
condition arising from or related to the HIV infection.
This bill requires DHFS to conduct a three-year pilot program under which
DHFS may pay premiums and copayments for drugs that are eligible for
reimbursement under the AZT-reimbursement program, for individuals under the
Health Insurance Risk-Sharing Plan (HIRSP), which is the health insurance
program that provides major medical health insurance coverage for disabled persons
covered under Medicare, persons with HIV, and persons who have been refused
coverage in the private health insurance market. The pilot program is limited to 100
individuals at any given time who: 1) are eligible for the AZT-reimbursement
program; 2) do not have health insurance coverage; and 3) are not eligible for the
health insurance premium subsidy program.
Currently, DHFS administers the Well-Woman Program, under which certain
medical services related to breast cancer, cervical cancer, and multiple sclerosis and
certain general medical services are provided to underinsured and uninsured women
of low income.
This bill requires health insurers, self-insured plans, service benefits plans,
and pharmacy benefits managers (third parties) to provide information to DHFS to
identify persons receiving benefits under the Well-Woman Program who are eligible,
or would be eligible as dependents, for third-party health care coverage and imposes
other requirements on third parties that are similar to those by which third-party
liability is determined and enforced under MA.
This bill does all of following:
1. Provides that the HIRSP Authority is to be treated as a state agency for all
purposes under the Wisconsin Retirement System, including the purpose of
providing fringe benefits, such as participation in the pension plan and health
insurance coverage, to its employees.
2. Requires the Investment Board, if requested by the HIRSP Authority, to
invest funds of the HIRSP Authority in the state investment fund and permits the
HIRSP Authority to participate in the local government pooled-investment fund.
3. Allows prescription drugs to be provided under HIRSP by a network of
pharmacists and pharmacies that are approved by the HIRSP Authority Board of
Directors.
4. Requires payments to providers under HIRSP to consist of usual and
customary payment rates instead of the allowable charges for services and articles
under MA.
5. Expands eligibility for premium and deductible subsidies to all persons with
coverage under HIRSP with incomes below a specified level.
Under current law, DHFS annually assesses hospitals a statewide total of
$1,500,000, in proportion to each hospital's respective gross private-pay patient
revenues during the hospital's most recent fiscal year. Moneys from the assessments
pay for a portion of MA benefits, certain long-term care pilot projects under COP, and
services under Family Care. This bill eliminates the current hospital assessments
and instead authorizes DHFS to collect an annual assessment on hospitals based on
claims. Under the bill, the assessments are based on a rate not to exceed 1 percent
of a hospital's gross revenues, as adjusted by DHFS. The assessments are deposited
into the health care quality fund, as created in the bill.
Currently, DHFS subsidizes the premium costs for health insurance coverage,
except for Medicare premiums, of low-income persons who are unable to continue
employment or must reduce employment hours because of illnesses or medical
conditions arising from HIV infections. Medicare has separate programs of coverage
for hospital care, physicians' services, and prescription drugs. This bill authorizes
DHFS to subsidize the premium costs for Medicare prescription drug coverage for
these persons.
This bill requires DHFS to award a grant of at least $167,000 in each fiscal year
to an organization for services to consumers and providers of supportive home care
and personal care.
Long-term care
Under current law, DHFS administers a variety of long-term care programs for
people who are aged or have a disability. Under the Community Options Program
(COP), Community Options Waiver Program (COP Waiver), and the Community
Integration Program for people who are relocated or diverted from nursing homes
(CIP II), counties provide community-based long-term care services to persons who
are aged or have a physical or developmental disability and qualify for MA. A
number of counties have implemented the Family Care program to provide
long-term care services for a capitated payment rate and information and referrals
related to long-term care options. Finally, in several counties, organizations
administer the Wisconsin Partnership Program or the Program for All-Inclusive
Care for the Elderly (PACE), capitated payment rate programs to provide both
long-term care and acute health care services to elderly people or people with
physical disabilities who are eligible for nursing home care.
Current law requires that DHFS obtain approval from JCF before expanding
use of capitated rate payment programs to provide long-term care services. This bill
eliminates this requirement.
Under the Family Care Program, DHFS contracts with resource centers to
provide information to interested individuals regarding long-term care services and
to determine eligibility for the family care benefit. DHFS contracts with care
management organizations (CMOs) to provide the family care benefit to eligible
people for a capitated monthly rate. CMOs must provide a variety of services under
the family care benefit including supportive living, personal care, supported
employment, and home health services, as well as nursing home and other
institutional care.
To be eligible for the family care benefit, a person must be at least 18 years of
age; have a physical or developmental disability or a degenerative brain disorder (a
qualifying condition); have a long-term or irreversible condition and be in need of
ongoing care or require care in order to maintain independence or functional capacity
(functional eligibility); and either be eligible for MA or have projected care costs that
exceed a specified portion of income and assets (financial eligibility).
Currently, five counties have both a resource center and a CMO, and an
additional four counties have only a resource center. Before DHFS contracts with an
entity to operate a resource center or a CMO in a county or for a tribe, the county or
tribe must appoint a local long-term care council and the council must develop a plan
concerning whether and how to implement Family Care. A single entity may not
operate both a resource center and a CMO. A county, alone or with other counties,
may create a special purpose district called a family care district that is independent
of the county to operate either a resource center or a CMO, and a tribe may establish
a corporation that is separate from the tribe to operate a resource center or a CMO.
The bill makes the following changes to Family Care:
1. The bill eliminates the requirement that DHFS obtain approval from JCF
before entering into a new contract for a resource center or a CMO, and before
entering into a contract with a private entity to operate a CMO.
2. The bill eliminates the current requirement that DHFS only make the family
care benefit available in areas of the state in which, in the aggregate, not more than
50 percent of the population that is eligible for the family care benefit resides.
3. Currently, only people who are eligible for both the family care benefit and
MA are entitled to the family care benefit. By January 1, 2008, DHFS must extend
entitlement for the benefit to certain persons who are not MA eligible. The bill
requires that a person be eligible for MA to receive the benefit, and thus eliminates
the requirement that DHFS extend, by January 1, 2008, entitlement for the benefit
to people who are not eligible for MA. The bill provides, however, that people who
are not eligible for MA but are receiving the benefit on the date this bill is enacted
continue to be eligible for, but not entitled to, the family care benefit.
4. The bill renames a family care district a long-term care district and provides
for tribes (acting alone or in conjunction with counties or tribes). The bill allows a
long-term care district to operate the Wisconsin Partnership Program or PACE, as
long as the district does not also operate a resource center. The bill also modifies
membership of long-term care district boards; modifies compensation and benefit
provisions for former county employees hired by a long-term care district; specifies
that counties are not responsible for providing or paying for services that a long-term
care district is required by statute or contract to provide or pay for; and provides for
a county or tribe to withdraw or be removed from a long-term care district.
5. Currently, the local long-term care council for a county or tribe is required
to review the performance of CMOs, identify gaps in services provided by the CMOs,
develop strategies for increasing availability of needed long-term care services,
advise the CMOs, monitor coordination between the resource center and CMOs, and
perform long-range planning for the long-term care system. The councils must
report to DHFS annually on achievements and problems of the local long term-care
system. This bill eliminates the councils and assigns some of their duties to the
governing boards of resource centers and some to regional long-term care advisory
committees, which are created in the bill.
The bill requires governing boards of resource centers to assess the availability
and adequacy of long-term care services, review coordination between the resource
center and CMOs, monitor complaints and appeals regarding the local long-term
care system, and develop strategies for increasing the availability for long-term care
services. The governing boards must report their findings to the appropriate
regional long-term care committee.
The bill requires DHFS to establish regions for regional long-term care
advisory committees. The governing body of each resource center must appoint a
number of members specified by DHFS to serve on the appropriate regional
long-term care committee. The duties of the committees include evaluating the
performance of CMOs and resource centers, monitoring grievances and appeals
regarding CMOs, reviewing the utilization of long-term care services, identifying
gaps in the availability of long-term care services, and performing long range
planning for the regional long-term care system.
6. The bill eliminates degenerative brain disorder as a qualifying condition for
the family care benefit, and instead provides that a person has a qualifying condition
if he or she is a "frail elder" (a person who is 65 years of age or older with a physical
disability or irreversible dementia that restricts the individual's ability to perform
daily tasks or that threatens the capacity to live independently).
7. Currently, a person may be functionally eligible for the family care benefit
at one of two levels, comprehensive or intermediate. This bill changes the two levels
to nursing home level of care and non-nursing home level of care.
8. The bill allows DHFS to determine by agreement with a county that has a
CMO the portion of the county's basic community aids allocation that is used to fund
the county's resource center and CMO.
9. The bill provides that counties in which the family care benefit is available
or in which the Wisconsin Partnership Program or PACE is operated may use their
COP funding to provide mental health or substance abuse services or to provide
services under the Family Support Program. Under the Family Support Program,
counties provide services to families of children who are disabled to assist the
families in caring for the children at home.
Under current law, community-based residential facilities (CBRFs) must
assess the financial condition of privately paying clients prior to admission and
provide them a statement that includes the estimated date on which the client would
deplete his or her financial resources by paying for care in the facility. If that date
is less that two years from the date of the statement, the CBRF must refer the client
to the county department responsible for administering long-term care programs to
assess the person's functional abilities, disabilities, and service needs and review
alternatives to institutional care. Counties generally may not use COP, COP Waiver,
or CIP II funds to pay for care in a CBRF unless the program recipient underwent
such an assessment before he or she entered the CBRF, regardless of whether the
recipient entered the CBRF as a privately paying client.
This bill repeals the requirement that CBRFs assess the financial condition of
privately paying clients prior to admission and the restriction on using COP, COP
Waiver, or CIP II funds to pay for care in a CBRF for a program recipient who did not
undergo an assessment of his or her abilities, disabilities, and services needs and a
review of alternatives to institutional care before entering the CBRF.
The bill repeals the requirements that adult family homes provide information
to prospective residents regarding Family Care resource centers and the family care
benefit and refer prospective residents to the resource centers. The bill also repeals
the requirement that hospitals refer patients to resource centers before discharging
them. Under the bill, CBRFs and residential care apartment complexes must
provide information regarding resource centers and the family care benefit to
prospective residents and, if a referral is required, refer prospective residents to
resource centers when the CBRFs or RCACs first provide the prospective residents
written material regarding their facilities. (A residential care apartment complex
consists of independent apartments, each of which has in individual lockable
entrance and exit, a kitchen with a stove, and individual bathroom, sleeping, and
living areas, and provides to a resident not more than 28 hours per week of
supportive, personal, and nursing services.) Also, in counties that do not have
resource centers, CBRFs must refer certain prospective residents who are aged or
have a physical or developmental disability to the county department responsible for
administering long-term care programs, and the county department must offer the
prospective resident counseling concerning public and private long-term care
benefit programs.
Under current law, intermediate care facilities for the mentally retarded
(ICF-MRs) must pay the state an assessment of $445 per month for each licensed
bed. Federal law provides for a reduction in federal funding for MA if the state
collects an amount in ICF-MR bed assessments that exceeds a specified portion of
the aggregate revenues of all ICF-MRs in the state.
This bill directs DHFS annually to set the monthly per bed assessment amount
at 5.5 percent of the projected aggregate annual revenues for ICF-MRs in the state
divided by the number of licensed ICF-MR beds and by 12 months. DHFS may
reduce the assessment amount during any fiscal year to avoid collecting an amount
during that year that exceeds 5.5 percent of ICF-MR aggregate revenues.
Under current law, nursing homes must pay the state an assessment on each
licensed bed that may not exceed $75. This bill raises that maximum amount for the
nursing home bed assessment to $127.
Under current law, the maximum number of licensed nursing home beds
statewide is 51,795. A nursing home may transfer a licensed bed to another nursing
home only under certain conditions. This bill reduces the statewide licensed nursing
home bed cap to 42,000 beds and provides that when a licensed bed is transferred,
the receiving nursing home must be in the same bed allocation area, as determined
by DHFS, or in an adjoining area.
Under current law, DHFS may approve a temporary reduction in the number
of beds licensed for a nursing home if the nursing home's occupancy rate falls below
the minimum per patient day occupancy standard established by DHFS. If the
nursing home does not resume licensure of the affected beds, DHFS must
incrementally revoke the license for the beds. This bill repeals the authority of DHFS
to reduce temporarily a nursing home's number of licensed beds.
This bill requires health insurers, self-insured plans, service benefits plans,
and pharmacy benefits managers (third parties) to provide to DHFS information
from their records to enable DHFS to identify persons receiving benefits under
Family Care who are eligible, or would be eligible as dependents, for third-party
health care coverage and imposes other requirements on third parties that are
similar to those by which third-party liability is determined and enforced under MA.
This bill requires DHFS to seek any waivers from federal MA laws that are
necessary to implement, in at least three pilot sites, an MA Program under managed
care for the long-term care of children with disabilities. The bill also requires DHFS
to award moneys in both years of the fiscal biennium for technical assistance and
planning services in support of family-centered managed care for children with
long-term support needs.
Under current law, the long-term care ombudsman may enter, without notice,
and have access to clients and residents of a nursing home, a CBRF, a place in which
care is provided under a continuing care contract, a swing bed in an acute care or
extended care facility, or an adult family home (a long-term care facility). The
ombudsman may communicate in private with a client or resident, review records
with consent of the client or resident or his or her legal counsel, and have access to
records of the long-term care facility or of DHFS concerning regulation of the
long-term care facility. Current law specifies the rights of residents of nursing
homes and CBRFs, including the rights to have private and unrestricted
communication with others, to present grievances without justifiable fear of reprisal,
and to be fully informed of all services, charges for services, and changes in service.
Current law authorizes the Board on Aging and Long-Term Care to contract to
provide advocacy services to potential or actual recipients of the Family Care
Program, or their families or guardians.
This bill expands the definition of a long-term care facility, for purposes of
activities by the long-term care ombudsman, to include residential care apartment
complexes. The bill provides that residents of residential care apartment complexes
are entitled to the same rights as residents of nursing homes and CBRFs. The bill
authorizes the Board on Aging and Long-Term Care to employ staff within the
classified service to provide advocacy services to Family Care recipients or potential
recipients, their families, and guardians.
Other health and human services
Currently, DHFS awards grants to prevent, reduce, or cease tobacco use. This
bill establishes the health care quality fund. The fund consists of moneys derived
from the increase in cigarette and other tobacco products taxes, moneys transferred
from the permanent endowment fund, and moneys from certain other sources.
Under the bill, moneys in the health care quality fund are used to fund, in part,
tobacco use control programs and for health care quality and patient safety
information.
Under current law, DHFS may recover incorrect payments made for health care
services under MA that resulted from certain action or inaction by an applicant or
recipient. If DHFS provides medical assistance to a person as a result of, for example,
an injury that was caused by a third party, DHFS may recover from the third party
the amount of the medical assistance provided. Also under current law, if an
individual who is obligated to pay support (court-ordered child or family support or
maintenance) has an overdue support obligation because of a failure to pay, his or her
name, social security number, and amount of overdue support is posted on a
statewide support lien docket.
